CNMI Governor Concerned About Cost Of Medicaid For COFA Migrants

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U.S. lawmakers pushing inclusion of migrants in federal medical program

By Haidee V. Eugenio

SAIPAN, CNMI (Saipan Tribune, July 8, 2013) – Gov. Eloy S. Inos supports congressional efforts to open up Medicaid eligibility to migrants from the Freely Associated States, but he wants it done the right way to prevent negative impacts on the CNMI’s limited finances, particularly by amending Section 4415 of S. 744, the sweeping immigration bill that the U.S. Senate recently passed.

Inos expressed his concerns in a three-page, July 3 letter to Delegate Gregorio Kilili C. Sablan (Ind-MP).

The letter came shortly after Inos and Sablan met on Capital Hill last week to discuss Medicaid coverage and other measures in Congress that affect the CNMI and other territories.

Section 4415, introduced as an amendment by Hawaii Sen. Mazie Hirono during a U.S. Senate Judiciary Committee markup on S. 744, removes the present cap on federal Medicaid payments to the U.S. territories for so-called COFA migrants. However, it retains the current matching requirement of 45 percent territorial and 55 percent federal funds.

In the long run, this could leave the CNMI "worse off as a result of Section 4415" if passed in its current form, Inos said.

COFA migrants refer to those from nations with which the United States has entered into compacts of free association. They include Palau, the Marshal Islands, and the Federated States of Micronesia’s Pohnpei, Chuuk, Yap and Kosrae.

Inos said as a last resort to mitigate the CNMI’s concerns, he would like to see the inclusion of a provision "granting state and territorial governors the discretion to opt-in or opt-out of the requirement that Medicaid cover COFA migrants."

Inos said Hawaii Rep. Colleen Hanabusa’s bill, H.R. 1222, contains such a provision.

"In closing, I must share that I am pleased to see that Congress is actively engaged in seeking ways to provide long overdue assistance to COFA migrants. This is certainly an issue very close to us given our rich history together under the former Trust Territory Government. All I’m asking for is that this be done the right way and for the benefit of everyone, U.S. and COFA citizens alike," the governor said.

S. 744 is the immigration reform bill that provides a pathway to citizenship for some 11 million undocumented aliens already in the United States.

This bill also has a provision allowing a pathway to citizenship for long-term, legal aliens in the CNMI.

Costs to CNMI

At present, some of the costs of providing health care services to COFA migrants in the CNMI are covered by Medicaid.

Inos said the Centers for Medicare and Medicaid Services has approved a state plan that allows for Medicaid to reimburse the CNMI for providing so-called Defined Emergency Services even if the patients, such as COFA migrants, are not enrolled in Medicaid.

These Defined Emergency Services include emergency room services, dialysis, day surgery, and hospitalization.

The CNMI State Plan also allows for Medicaid coverage of pregnant women and children from the Freely Associated States.

Last year, a total of 1,307 patients from FAS were covered in this manner at a total cost of $I.75 million, Inos said.

The governor said the CNMI’s local share was $789,840 and the federal share was $965,360.

He said Section 4415 would not change this existing coverage or the territorial/federal shares of costs.

Instead, Section 4415 "would source the federal share from funds other than those currently capped by Section 1108 of the Social Security Act."

These capped funds include both the longstanding annual amounts allocated to each territory, as well as the new funds provided as a result of the Affordable Care Act.

"Thus, if Section 4415 had been in effect last year, the $965,360 federal share, which paid for health care for COFA migrants, would have eventually instead been applied to the cost of health care for U.S. citizens eligible for Medicaid," Inos told Sablan.

In addition to the COFA migrants covered by Medicaid under terms of the CNMI’s State Plan, the CNMI also expended $488,800 of local funds in 2012 to provide health services to other COFA patients, who required care not eligible for any type of Medicaid coverage at the Commonwealth Health Center, Inos said.

Assuming all these patients met the income threshold and any other Medicaid eligibility requirements, 55 percent of this expenditure amount, or $268,840, would have been covered by the federal government, if Section 4415 had been in effect, Inos said.

Based on historical data, Section 4415 would have been of benefit to the CNMI because capped, territorial Medicaid funds would not have been diverted to pay for COFA migrant health care and 55 percent of the funds expended by the CNMI for some of this care would have been saved.

"Looking forward though, there is risk to the Commonwealth’s finances if Section 4415 goes into effect," Inos said.

He said the number of persons covered is likely to increase.

The 2010 Census reported 3,169 COFA migrants in the CNMI. Inos said although the Commonwealth already provides Defined Emergency Services and other care to some of this population, "if all are qualified for Medicaid, the number receiving services is very likely to rise."

"And the Commonwealth will be responsible for 45 percent of the increased cost. We may also see the range of services being provided expand, as, presumably, COFA migrants could not be made ineligible for any care that is available to any other Medicaid patient under the terms of our State Plan. Increased utilization means increased cost and, again, the Commonwealth will be responsible for 45 percent of that cost," he said.

He added that there is the risk of future increases in the cost of medical equipment, supplies, and personnel who provide care.

"Even if the 55 percent offset of total costs seems attractive at present, providing more care to more people at inflated rates in the future could put the Commonwealth right back where we started or in an even worse financial position," he said.

‘Not outright opposition’

The governor said these concerns do not mean outright opposition to Section 4415.

In fact, he said, proposals regarding Medicaid coverage of COFA migrants already before Congress could improve the problems he has identified.

"In particular, I would strongly support the addition to Section 4415 of language similar to that in H.R. 1222, introduced by Hawaii Rep. Colleen Hanabusa," he said.

Hanabusa’s bill provides that the federal medical assistance percentage for COFA migrants will be the same percentage as is applied to medical assistance for services received through a Native American Health Service Facility.

This one change to Section 4415 would end all of the forward risk for the Commonwealth, Inos said.

At the same time, by assuring that low-income COFA migrants will have access to the same services as any other Medicaid patients, this change would have a substantial, positive benefit for public health in the CNMI, the governor said.

There is no telling about the fate of S. 744 in the U.S. House of Representatives.

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